Healthcare Provider Details

I. General information

NPI: 1871311027
Provider Name (Legal Business Name): JPB MONTANA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/27/2024
Last Update Date: 09/27/2024
Certification Date: 09/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3027 MT-83 SUITE L
SEELEY LAKE MT
59868
US

IV. Provider business mailing address

410 1ST AVE W
KALISPELL MT
59901-4809
US

V. Phone/Fax

Practice location:
  • Phone: 406-677-3617
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ALISHA BASLER
Title or Position: AUTHORIZED AGENT
Credential:
Phone: 406-261-9401